Abstract Kidney transplantation offers longer survival, better quality of life, reduced hospitalization, and lower cost relative to dialysis for the >500,000 end-stage renal disease (ESRD) patients on dialysis in the US. Despite this evidence, only 18.5% of ESRD patients are waitlisted for a kidney transplant. Extensive population research has identified substantial variability in kidney transplant access among US ESRD patients as well as dialysis facilities and transplant centers due to patient-, neighborhood- and health system-level factors, but no national surveillance data exist on early kidney transplant steps. Our overarching, long-term goal is to eliminate inequities and improve healthcare delivery for ESRD patients in every step of the highly complex kidney transplant process. Our specific aims are to: (1) describe dialysis facility and transplant center differences in early steps of the kidney transplantation process, including a) referral for kidney transplant evaluation, b) start of the transplant evaluation process, and c) placement on the national deceased donor waiting list and (2) determine the patient-, neighborhood-, and health center-level barriers that explain disparities in these early steps of kidney transplantation among participating ESRD Networks in the Southeast US, Northeast US, and Ohio River Valley, and determine how barriers vary across geographic region. This study will be conducted in a geographically diverse population of ESRD patients in the Southeast (GA, NC, SC), Northeast (CT, MA, ME, NH, NY, RI, VT) and the Ohio River Valley (IN, KY, OH) representing 48 transplant centers, ~1,800 dialysis facilities, and ~155,000 incident ESRD patients. With these novel data, we will conduct critical epidemiologic analyses to describe regional variability in several outcomes, including: a) dialysis facility-level kidney transplant referral rates, b) dialysis facility-level evaluation start rates, and c) transplant center waitlisting rates among those who initiated the evaluation process. In Aim 2, we will identify the barriers to these important transplant steps using multilevel models as well as dialysis facility and transplant center provider surveys and patient focus groups. This work will help to identify the geographic regions and the dialysis facilities with the lowest rates of kidney transplant referral and evaluation and better understand the characteristics of the populations with lowest rates of transplantation access. Findings will be disseminated to the respective ESRD Network leaders in each geographic region as well as to transplant centers and other stakeholders, where they can target regional quality improvement efforts to improve access and reduce disparities in kidney transplantation. Results will also inform future multi-level and multicomponent interventions adapted to fit the needs of each geographic region.